Global Benefits Magazine | Issue 5 by MT Association

APRIL 2011

Get the 411 on Travel Health Insurance PG 6

Keeping Your Employees Safe While Abroad PG 9

Risky Business: Are Your Employees Covered Abroad? PG 15

April 2011 // Issue 5

FEATURES 6

18 Is your Organization a Healthy Enterprise? By Steven Cyboran

23 A Profile ~ Bill Baun

Manager, Employee Wellness programs, MD Anderson Cancer Center, Houston TX By Jane Sherwin

26 Utilizing Single Specialty Medical Centers By Alejandro Badia

Get the 411 on Travel Health Insurance By Brendan Sharkey

Keeping Your Employees Safe While Abroad By Vaughn Volpi

Risky Business: Are Your Employees Covered Abroad? By Joe Harbon

30 Expatriate Health Insurance:

How to Apply Moratorium or Medical Questionnaire By Olivier Le Faouder

32 Healthcare and the Impact on the Federal Budget By Melvin J. Howard

36 The International Traveler and Blood Transfusions By Katherine L. Harmon

39 Tooth-Enomics

By Mark Roberts

Letter From the Editor

How Employers and Insurers are coping with Global Emergencies By Jonathan Edelheit It seems that over the past year or so, it has been one disaster after another, whether natural or man-made. This has created a whole new challenge for employers and insurance companies with insured and representatives in different parts of the world. We have had revolutions in Egypt, Tunisia, Libya, and Yemen, earthquakes in Haiti and other countries and now the Tsunami and nuclear crisis in Japan. Employers and insurance companies have had to evacuate people, coordinate rescue missions and coordinate medical evacuations in larger numbers than ever before, and some truly global organizations are dealing with disaster after disaster as they have employees in countries around the world. Insurers and Employers are for the first time really finding out if their disaster and crisis plans actually work. They are evaluating how well they are working and realizing that many are unprepared and need to put in new plans and processes. We are in a new world and we need to be prepared for it.

Jonathan Edelheit

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Get the 411 on Travel Health Insurance

Get the

411

on Travel Health Insurance

By Brendan Sharkey

cores of Americans are traveling the globe for leisure, business, study and missionary travel. As international travel marches on, travelers seem to be faced with an ever increasing number of health and safety concerns. Travel concerns run the gamut from pandemics such as the H1N1 virus to safety threats like those seen recently in Egypt. Given the heightened risk, smart travelers are planning and preparing more than ever to avoid potential hazards.

Why has Travel Health Insurance Increased in Popularity? Although health and safety concerns have contributed, strong growth is tied to greater consumer awareness. The simple fact is that existing health insurance plans are inadequate when taken across U.S. borders because they strictly limited overseas benefits. In addition, most health insurers will refuse to pay to get you to a higher standard of care should you need to be evacuated due to a medical emergency. Savvy travelers are aware of these limitations and are not leaving anything to chance.

What will a Good Travel Health Policy Do for You? Travel health insurance policies are designed to pick up where your primary health plan leaves off. If you do not have health coverage, these plans act as primary insurance while abroad. The best designed plans offer more than emergency benefits. They cover big ticket items such hospitalization and surgeries but will also pick up the tab on physician office visits, ambulance services, prescription medications and more. The premier plans make it a point to cover sickness or injury due to a terrorist event or a pre-existing medical condition. Critically, some policies will pay medical providers overseas on a direct basis so you can avoid hassles and red tape.

Admitted Coverage versus Non-Admitted Coverage Travelers need to understand that there can be big differences in their coverage rights when they buy travel health insurance. Some plans are licensed and regulated in the U.S. while others sit offshore: beyond the reach of your local Department of Insurance. U.S. licensed and approved plans are called admitted insurance. 7

Comparing admitted to non admitted policies is truly an apples and oranges comparison. They are built very differently with important implications for the policyholder and selling agent. Your personal health and financial security could hang in the balance.

Admitted Health Insurance Advantages Include: 1. Consumer & Agent Protection You are protected under U.S. insurance laws and oversight. U.S laws are strict and favor health care consumers. Policy language is reviewed, must be fair and meet the plain English definition. Policy wording, plan definitions, exclusions, claims turnaround times, appeals process etc. all must meet regulatory muster. Also, the issuing carrier must meet financial solvency standards. In addition, a health insurance agent selling an admitted health product is covered under their E&O policy.

2. Global Provider Networks What good is insurance if you canâ&#x20AC;&#x2122;t find a doctor you trust? The best plans give you access to the best providers. They set up providers to bill the insurance company directly. In addition, providers are selected based on their medical credentials, language proficiency and more. Always ask the insurer what their credentialing process entails. 3. Richer Benefits Admitted benefits tend to be broader and deeper with fewer surprises at time of claim. The table below illustrates major differences between an admitted policy and a typical non admitted policy.

Sample Provisions Admitted Policy

Coverage Considerations

Sample Provisions Non-Admitted Policy

Conforms to U.S. health insurance laws Pre-existing conditions covered to policy limit* Terrorism covered with no excluded countries Pre-certification not required for hospitalization Cashless access to profiled physicians and hospitals in 180 countries *Pre-existing conditions coverage may be subject to current enrollment in a primary health plan.

Healthy, Safe Enjoy peace of mind with a well built travel health plan. As with everything in life, it is a good idea to do your home work. Always ensure that you read the fine print rather than just scanning a benefit schedule. Ask your broker or insurance company to send you a sample policy so you can get a complete picture of what youâ&#x20AC;&#x2122;re buying.

ABOUT THE AUTHOR Brendan Sharkey is the Director of Individual Products for HTH Worldwide. From the nuts and bolts of travel and international health insurance to the crucial themes of global health and safety, Brendan is frequently called upon to discuss the insurance landscape. He may be reached at bsharkey@hthworldwide.com

About HTH Worldwide HTH Worldwide is a leader in helping world travelers gain access to quality healthcare services all around the globe. HTH combines ongoing research, a contracted global community of physicians and hospitals, advanced Internet applications, and wide experience in international health insurance to ensure customers' health, safety and peace of mind. Visit www.hthworldwide.com

Keeping Your Employees Safe While Abroad

Keeping Your Employees Safe While Abroad By Vaughn Volpi

re your employees and corporate travellers prepared in the event of an emergency? With little to no lead time would you know how to evacuate them in the event they were caught in the middle of the social, political and criminal unrest thatâ&#x20AC;&#x2122;s spreading around the world? Do you have trusted incountry resources that can insure their safety while the evacuation is being organized?

Sadly most multi-national corporations with travellers and ex-patriates living abroad have large holes in their security and risk mitigation programs. In most cases this is not due to indifference, cost, or even negligence. It’s typically a lack of the trustworthy local resources capable of operating safely and effectively in volatile environments. Government agencies around the world have learned the hard way how important localized sources are in identifying, evaluating and addressing risks abroad. It’s even more critical for multi-national corporations who are required to operate in dangerous locations yet don’t have the benefit of a governmental security apparatus. While Embassies and other home nation resources are helpful for routine matters, they quickly become overburdened and unreliable when a crisis erupts, or an individual is specifically threatened. When this happens it’s critical that companies have a trustworthy and strong in-country team that can respond when conventional channels shut down.

Countering Threats The first step in establishing a strong in-country support program for corporate travellers and expatriates personnel is to identify the issues you may be required to mitigate. These obviously vary from country-to-country but in general companies should have a plan and the local resources to address all of the following;

• Political unrest including a shutdown of the basic • • • • • • • •

governmental infrastructure Public corruption Terrorist attack Natural disaster Serious illness or accident Kidnapping Blackmail or extortion Organized criminal activities Random criminal acts

Each of these threats, and others which are industry or country specific, require individual mitigation strategies and teams. Many companies tend to view the world through the lens of their home country. This can be a positive when attempting to elevate ethical and productivity standards to first-world levels. However, it’s important to remember that even developed nations struggle during times of crisis. Hurricane Katrina was a clear example. Despite one of the most sophisticated crisis management systems

in the world (and plenty of advance notice of the impending threat) the remaining population in New Orleans experienced unprecedented violence and strife for many days following landfall. When a crisis hits the third world, abject chaos often follows. While contingency planning can’t prevent the destruction of Hurricane Katrina or the political unrest in Egypt, it can help companies insure that their personnel and key assets are secure. When corporate security and risk management personnel undertake this task it’s critical they do so with the understanding that the infrastructure and personnel they count on everyday are likely to collapse. It’s for this reason that it’s critical that all mitigation strategies are developed in concert with trusted, in-country risk management experts. Many companies are large enough to have regional security teams who can provide this input, however it’s important to differentiate planners from responders. In times of crisis the regional security team may not be available or even qualified to mitigate the issue. This is where trusted local resources are critical to success.

Finding In-country Resources A wise statesman once said, “In time of peace, prepare for war”. This is especially true when identifying your local security, intelligence, and crisis response teams. There is often not enough time to carefully vet in-

country personnel once a crisis is raging. This leads to failure at times when success is the most critical. Even if you happen to select a capable asset, you risk them not having the band-width or familiarity with your company to maximize their performance. Here are a few tips for selecting in-country personnel for your response teams; • Carefully vet your resources to insure they are reputable and trustworthy. Ask them for referrals and speak with your industry colleagues about their in-country resources.

• Avoid a knee-jerk reaction to select the lowest-

•

priced vendor. In many developing countries low prices often equate to corners being cut or bribes replacing standard operating procedures. To avoid corruption and maximize success, find a vendor with high profile local personnel. This enables projects to move forward quickly based on their keen understanding of the host country’s systems, and their long-standing relationships.

• Make sure you have the best specialized resources for every situation. The company that provides close personal security is not likely to be the best for medical evacuation, or hostage negotiation.

• Try to visit as many of your vendors as possible

while travelling on other business. Only select organizations that are using local national personnel. In most crisis situations a trustworthy local national is more effective than an expatriate based on their deeply rooted contacts, understanding of the culture, and ability to move about freely in hostile situations.

• Make sure the organization you engage is

large enough to withstand a regionalized crisis themselves. Many security guards in New Orleans abandoned their posts to take care of their own families when Katrina hit. As a result many facilities went unsecured until companies hastily arranged for guards from out-of-state.

• Build in redundancy. Have at least three vendor options in the event your preferred vendor can’t perform.

• Use your resources periodically in non-crisis situations (e.g. close protection details, threat assessments, due diligence inquiries) to test their professionalism and capabilities. You don’t want to find out during an emergency that your vendor is weak.

• Make sure to execute master services agreements

with your primary vendors. These agreements should describe their services, pricing, and your expectations for work product and ethical practices.

• Take a zero tolerance policy on corruption. In many countries bribes are considered almost customary, so make sure your local vendor understands that they’re working for a multi-national organization with different standards.

Three Low Cost Solutions to Consider Intelligence Programs For volatile countries, or countries where your company has a large corporate presence, it makes sense for your security personnel to have an ongoing threat intelligence program. These programs provided hour-to-hour updates on issues which affect the company’s personnel and facilities. It’s important that these programs go beyond the traditional travel risk management software which is now commonplace in multi-national corporations. These online services should be used as a point of departure for human analyst-driven programs which are specifically tailored to the client’s unique situation. This enables human resources to be re-vectored quickly in response to new threats, often giving the company the opportunity to prevent a crisis before it fully develops.

Personnel GPS Systems Applications are now commercially available that enable any company smart phone to be tracked at all times anywhere in the world. After a simple 2 minute download the phones use a combination GPS and cellular technologies to feed information back to a secure web site that can only be accessed by approved risk management personnel. The system also includes a panic button and instant messaging system to dispatch critical communications to personnel in threatened geographies. The systems are very low cost (approximately a dollar per day) and should be standard issue equipment for all corporate personnel travelling or working abroad. On Call Crisis Response Companies with a concentration of ex-pats or travellers in a specific geography should consider establishing an on call crisis response system. All travellers and ex-patriates are given a 24 hour number for a personal crisis response expert in their area. That individual is immediately available to offer advice and/or response for any incident which may arise. This service has become very popular with companies who are interested in providing security for their executives and personnel travelling in unfamiliar environments, without incurring the cost of a personal security detail. Typically the client is billed a modest monthly fee for having personnel standing by for deployment, and are then billed by the hour for any response that is required. This saves money and provides security for travelling corporate executives, and in-country ex-pats alike.

ABOUT THE AUTHOR Vaughn Volpi joined PICA Corporation in 1989. In 1996 he was named President and assumed responsibility for the day-to-day operational and financial management of the company. In January 2010 Vaughn ascended to his current role of Chief Strategy Officer.

About PICA Corporation PICA Corporation, established in 1982, is one of the largest companies in the world dedicated to risk management, corporate security, business intelligence, and brand protection operations. The U.S.-based company represents over 700 multi-national corporations in these areas. For more information visit: www.pica.net.

Risky Business: Are Your Employees Covered Abroad?

Risky Business:

Are Your Employees Covered Abroad? By Joe Harbon

gypt. Jordan. Bahrain. Recent headlines tell the tales of political unrest and hazardous situations around the world. For multinational companies, insuring employees against the risks of doing global business should not be overlooked.

As multinational corporations expand into markets outside the USâ&#x20AC;&#x201D;markets that may have been recently added to the US State Departmentâ&#x20AC;&#x2122;s travel warning listâ&#x20AC;&#x201D; and as more and more countries strain under the tensions of wartime, economic uncertainties and government upheaval, the amount of human resources in adverse or volatile locations has also increased. Human resources directors for multinational companies must now prepare a responsible benefits package to protect its personnel against a unique set of risks.

War and Terrorism (W&T) The W&T exclusion you’ll find in most global benefit plans is usually reserved for employees or contractors traveling or conducting business in a traditionally hostile zone. Iraq, Afghanistan, Yemen, Sudan and many other OFAC countries for which either the Department of Treasury or the US State Department have issued a travel warning come to mind. Recently, however, historically passive countries like Spain, India and Ireland have seen a rise in acts of terrorism. In fact, the list of countries or regions falling victim to terrorism and the sheer number of terrorist attacks is growing at an alarming rate. In 2008 alone, a US State Department report documented 11,770 terrorist attacks worldwide with 54,747 people killed, injured or kidnapped. Sadly, as US and international corporations expand into new global markets, the number of these incidents appears to increase. Because terrorism can no longer be considered a problem in a few geographic locations—it is becoming a worldwide risk factor—the need for human resources and benefits managers to adequately protect against possible losses due to terrorism has become a critical matter. Some insurance carriers have tried to mitigate this risk with a W&T rider to the entire company's group policy.

For most companies who have a relatively small percentage of their personnel traveling abroad, a rider of this scope is too expansive and costly. Furthermore, these types of riders still impose aggregate limitations as well country restrictions. The smarter choice for companies doing international business is a carveout of only those employees doing business abroad. This allows for sufficient coverage without incurring the higher premium involved with covering the entire company—the majority of which are not exposed to the risk.

W&T Carve-Out for Key Personnel The employee or contractor exposed to the W&T risk is often times a highly compensated executive, principal or owner. Protection for these key personnel is usually addressed in the well-written benefits plan, but their coverage may come up short because of policy maximums or W&T exclusion. Many life insurance policies, including Key Man policies, are progressively rated based on past, current and future travel destinations. It is usually more cost beneficial to carve-out and issue a W&T policy for these key staff members on a per trip or assignment basis. Will Defense Base Act (DBA) insurance sufficiently alleviate the W&T risk? Simply put: no. This legislated insurance requires companies to extend coverage to acts of war and terrorism and provide injury and death benefits up to 200 percent of the national average weekly wage or 200 percent of the employee’s full average weekly wage, whichever is smaller. The problem with DBA insurance, and why it won’t work to protect your key personnel, is that the injury and death benefits are far too low. At just two times the insured’s weekly salary, DBA insurance leaves your key personnel dangerously underinsured. Financial advisors recommend a policy, or policies, whose benefits pay seven to ten times the insured’s annual salary. Since most employees don’t carry an individual policy to provide this level of benefit, relying on DBA insurance alone will not properly protect your employees for loss of life or injury.

International Disability In 2007, the Social Security Administration reported that 70 percent of the private sector workforce had no long-term disability insurance. Further compounding the problems for under- or uninsured personnel, in the event of a W&T-caused injury there is limited coverage—usually a lump sum payout—for long-term disability. So workers affected by a disabling injury, even with DBA coverage, will most likely fall short if the disability is long-term. With highly compensated executive or key staff members at risk the problem increases significantly, but a carve-out solution to protect these key personnel in the case of W&Tcaused injury proves again to be quite beneficial.

Kidnap and Ransom (K&R) Lastly, K&R policies are among the least understood policies for human resources and benefits managers. Since K&R incidents are often kept private as a safety precaution, the insurance industry has limited data about the actual risk of these occurrences. The likelihood of incident may very well be low, but a K&R scenario could prove tremendously expensive should it happen. While some countries pose more of a risk than others, for many traveling executives this is a real threat wherever they may go. These policies are designed to reimburse the policy owner for all expenses incurred with a kidnap for extortion.

Specialized Solutions for International Workers As we’ve just outlined, employees working abroad carry a unique set of risks that are sometimes underestimated and rarely anticipated. DBA insurance is not an adequate solution—especially for key personnel or those at risk for long-term disability—W&T riders applied to an entire group plan are unnecessarily costly, and with terrorist activity on the rise the need for specialized policies like K&R is becoming an alarming reality. As more and more companies send their workers into the global market, human resources and benefits managers will need to procure a variety of specialty insurance plans. Enlisting the help of insurance providers specializing in W&T, international disability and K&R insurance will ensure the right coverage for their specific needs. Furthermore, creating carve-out policies for key personnel and staff working overseas will keep premiums low for the company as a whole, while providing the protection international workers deserve.

ABOUT THE AUTHOR Joe Harban is an International Policy Specialist for ISA, a global insurance provider specializing in custom insurance solutions for a variety of unique needs including war and terrorism, disability and kidnapping and ransom insurance. Joe works directly with human resources personnel to create need-specific retirement, group and travel benefits for multinational and domestic corporations. You may reach him at joe@isabrokers.com

Is your Organization a Healthy Enterprise? By Steven Cyboran

major, but often unrecognized, factor underlying most employers’ health care problems is that the current system was designed to treat rather than prevent illnesses. The result, as Dr. Nancy Nielsen, the president of the American Medical Association, noted, is that “We are living longer, but we are not living healthier.” Moreover, the relatively poor health of Americans has the potential to undermine an organization’s ability to execute its strategy. For example, according to one study, employees who have three or more health risks have health care expenditures that are 38 percent higher and absence-related costs (i.e., shortterm disability, workers’ compensation and incidental absence) that are 30 percent higher than those for employees who have fewer risks. In addition, the costs of health-related productivity problems are, on average, 2.3 times greater than medical and pharmacy costs. To build on this notion, the World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of infirmity.”

Recognizing these factors, some forward-thinking organizations — what we call healthy enterprises — have taken steps to address both the health and the health care needs of their employees. They do so by partnering with their employees on not just health care problems, but also on preventive health care solutions that aim to optimize health and fitness, not just eliminate risks. This shift is evident in the orientation many organizations demonstrate as they strive to become a full-fledged healthy enterprise.

Optimal Health A number of organizations are taking a growing interest in the holistic health of their employees to promote complete health and fitness. Optimal health is defined as “a balance of physical, social, spiritual and intellectual health.”* *Source: O’Donnell, American Journal of Health Promotion, 1989 3(3):5

The Continuum of a Healthy Enterprise Based on investigations of best practices, our independent research and experience with clients, Sibson Consulting has identified three stages of healthy enterprises:

1. Focus on Treatment In the first stage of the

continuum, the focus is reactive rather than preventive. The organization addresses behaviors and health issues after they occur. Many organizations in this stage become aware of issues through large claims increases or workplace incidents and concentrate on reducing costs rather than improving health and behavior. Enterprises that focus on treatment may overlook the costs associated with productivity losses caused by health-related absences or disruptive workplace behavior.

2. Focus on Prevention/Management In the second

stage of the continuum, the focus is more proactive. The organization promotes better physical and mental health for employees and family members by helping them to identify health risks and conditions and then address them through supportive resources. Companies in this stage are increasingly proactive in sharing responsibility and encouraging safety, personal accountability and health risk and condition management through healthy personal and workplace behavior.

3. Focus on Optimal Behavior and Health In the

third stage of the continuum, the focus moves beyond risks and conditions to a demonstrated commitment to improve the health and behavior of employees and the organization. This is imbued throughout the culture as a means to enable employees to engage fully in their work and their personal lives. (See the sidebar “Optimal Health.”) Evidence of a “healthy culture” is reflected in all aspects of organizational behavior, from encouraging a team-based environment with a climate of trust and respect to maintaining a smoke-free environment. Healthy behavior is encouraged, exhibited and rewarded. Some healthy enterprises also consider the financial wellbeing of their employees as part of the total picture.

Trying to achieve a healthy culture right out of the blocks can be a daunting task that is outside the scope of HR. A more realistic approach is to start by defining a strategy that clearly aligns with and supports the business strategy. Companies can then begin by making investments that optimize success within the current culture. Many organizations start promoting health and wellness by repackaging the programs and services they already have in place to support the strategy. They then add resources (e.g., health-risk assessments and screenings) to help employees and their families understand their risks and conditions and to better manage them through behavior modification (e.g., using health coaches, education and other tools).

How Healthy Is Your Organization? A number of factors differentiate the three stages of a healthy enterprise. For example, where an organization in the first stage will primarily be reactive in treating conditions and dealing with unacceptable behavior, an organization in the second stage will focus on managing risks and conditions by shaping behavior. An organization in the third stage, however, will focus on optimizing health and behavior by maintaining a healthy culture that is evident at every level of the organization. In addition to this strategic orientation, each stage of maturity is characterized by its approach to addressing the various elements of its programs/initiatives, such as health plans, time-off programs, workplace support, behavioral health programs, communications, organizational behavior and measurement and metrics. (See the table below, for a sample of key distinguishing features.)

KEY DISTINGUISHING FEATURES ALONG THE HEALTHY ENTERPRISE CONTINUUM Focus on Treatment

Focus on Prevention/Management Characteristic Distinguishing Features Provides high-quality and costReduces health risks and manages Health effective treatment conditions Replaces pay, manages disability and Advocates safety, accountability and Time-Off returns people to work risk management

Focus on Optimal Health/Behavior Optimizes health and fitness Promotes life-long health and personal and professional renewal

Behavioral Health

Addresses personal and work-related Addresses factors leading to substance Promotes a “whole-life” approach to mental health/substance-abuse issues abuse and mental health issues maximize all aspects of personal wellbeing — mind, body and spirit Shapes desired behavior Organizational actions are consistent Organizational Addresses unacceptable behavior with the organization’s values Behavior Source: Sibson Consulting

Three Health-Focused Enterprises: One Hypothetical Employee’s Experience One way to illustrate the differences in the three stages of a healthy enterprise is to look at what would happen to a key employee named D.K. (a 55-year-old male who is at risk for developing heart disease), depending on the kind of organization for which he works: • Focus on Treatment D.K. is driven to develop risk factors for heart disease by years of eating unhealthful food coupled with increasing pressure in the workplace. His underlying risk factors go undetected for years and his heart disease is likely to be diagnosed as the result of a medical emergency. D.K. may need surgery, which will mean an extended absence from work and lost productivity. When he returns, he may find it hard to commit to healthier behavior due to stresses and temptations in the workplace. D.K. also will be challenged to get the mental and emotional support he needs to change his health-risk behavior.

• Focus on Prevention / Management D.K. receives strong support at work and may become aware of his risk for heart disease through a health-risk assessment, for which he receives an incentive to complete before he develops clear symptoms. He may also receive support from various programs to delay the onset of the condition, but he will still face challenges in the workplace and will probably revert to his previous behavior.

• Focus on Optimal Health and Behavior D.K. works in a strongly supportive environment that encourages and incentivizes healthy behavior, which makes him less likely to develop risk factors for heart disease. He learns the importance of personal renewal and taking care of his health for both personal and professional reasons. D.K. understands the organization’s commitment to a healthy workforce. Moreover, he views the organization as a support system for a healthier lifestyle, with leadership serving as models of healthy behavior and an environment with limited temptations and potential pitfalls.

How to Become a Healthy Enterprise The first step to becoming a healthy enterprise is to develop a healthy enterprise strategy and identify opportunities for improvement. (For a look at the outcomes achieved by one organization, see the sidebar “Research University and Health System Case Study.”) Some of the steps that may be part of the strategy development include:

• Develop a philosophy and strategy, a health and

•

productivity mission and vision that supports the organization’s goals and fits its culture. Establish clear guiding principles that become the foundation for testing each current and future investment made. The strategy statement will shape the focus of the initiative. Conduct a wellness inventory to identify the existing wellness benefits and practices included in the organization’s health and welfare plans (i.e., medical, prescription drug, disability, dental and vision) as well as any supplemental wellness benefits (i.e., an employee assistance program, work/life programs, safety training, online resources and official/unofficial workplace programs and support). Assess the effectiveness with which wellness benefits and programs are branded, communicated and made accessible to employees. Look at whether current practice supports the organization’s vision and strategy and determine whether the health plan presents barriers to healthy behavior (e.g., no coverage for nutritional counseling). Establish a metrics scorecard to measure the progress of achieving the strategy. Although there may be thousands of items an organization may track and measure, an organization needs to be selective and identify those key metrics that will track progress toward achieving the stated

•

strategy. Metrics need to include markers that lead to success (e.g., participation, satisfaction and behavior change) as well as the outcomes themselves. This requires looking beyond utilization and biometric statistics that just measure physical health. Research indicates that there are actually five dimensions to our health (physical, intellectual/ mental, emotional, social and spiritual) that need to be measured. In addition, organizational measures need to be included (e.g., a climate of trust and respect). Conduct a cultural assessment to review the behavior that affects the organization’s health. This evaluation needs to examine the relationships between the organization’s healthy enterprise investments and the employees’ sense of affiliation, work content, career opportunities, benefits and compensation. Establish a communication strategy to get leadership and the workforce to embrace the initiative and shape the desired behaviors.

After an organization has defined its strategy, it needs to devise a plan to implement it. It is of utmost importance to keep things fresh and respond to new ideas and initiatives as they present themselves.

Conclusion Most organizations seek to optimize their workforce by reevaluating all of their investments to determine what is essential to carry out their business strategy while maintaining and enhancing the current and desired culture of the organization. A well-thought-out healthy enterprise initiative can lead an organization to better control its health care, turnover and absence-related costs while helping its employees stay engaged, healthy and productive.

Research University and Health System Case Study A large research institution with extensive investments in various health initiatives aimed at controlling costs, requested assistance to:

• Facilitate discussions between its faculty, staff and

leadership to define the desired state of health care

•

on campus, and Identify the metrics and stages of maturity across the different dimensions of a healthy campus so it could measure and communicate progress.

The Solution Sibson Consulting helped conduct literature research to identify state-of-the art practices in both higher education and business. Sibson worked in partnership with the institution to develop a “straw man” of the desired state that was used in focus groups with key clinical and administrative leaders to finalize the desired state and profile of a healthy campus. Metrics were developed to measure the current state along with the institution’s progress along the stages of maturity toward its desired state.

Result The institution’s health care costs have increased only 1 percent per year for the past four years. There has been significant improvement in participation, compliance rates, rates of absence and outcomes for targeted programs addressing prevention, diabetes, cardiovascular disease and pediatrics. Annual savings are conservatively estimated to be approximately $18 million. Specific documented outcomes include:

• Reduced rates of hospital admissions, emergency

Resources • “America’s Health Checkup [link to: http:// www.time.com/time/specials/packages/article/0,28804,1860289_1860561_1860562,00.html],” Time, December 1, 2008. • “Association of Health Risks With the Cost of Time Away From Work [link to: http://journals.lww.com/ joem/Abstract/2002/12000/Association_of_Health_ Risks_With_the_Cost_of_Time.6.aspx],” Journal of Occupational and Environmental Medicine, Volume 44, Issue 12, 2002. • "Health and Productivity as a Business Strategy: A Multiemployer Study [link to: http://journals.lww.com/ joem/Abstract/2009/04000/Health_and_Productivity_as_a_Business_Strategy__A.4.aspx]," Journal of Occupational and Environmental Medicine, Volume 51, Issue 4, April 2009. • Sibson Consulting’s 2007 Healthy Campus Survey [link to: http://www.sibson.com/publications-andresources/surveys-studies/?id=253]. • See “Is Your Wellness Program a Scattershot Effort … or on Target to Serve Employees and the Organization?” [link to http://www.sibson.com/publications/ perspectives/volume_16_issue_3/pdfs/wellness.pdf] Perspectives, June 2008. • Source: O’Donnell, American Journal of Health Promotion, 1989 3(3):5 For more information on these five elements — sense of affiliation, work content, career opportunities, benefits and compensation — see Sibson Consulting’s Rewards of Work Study [link to: http://www.sibson.com/publications/surveysandstudies/2009ROW.pdf]. See “Reaching Employees in the Right Place at the Right Time: Four Steps to Successfully Communicating Your Organization's Wellness Program,” [link to http:// www.sibson.com/publications/perspectives/Volume_16_ Issue_4/pdfs/wellness.pdf] Perspectives October 2008

room visits and average lengths of stay for those admitted to the hospital,

• Lower health risks with large percentages of

•

participants becoming risk-free (e.g., over five years, 69 percent of participants who were at risk for cholesterol and 59 percent for blood pressure became risk-free); the institution’s smoking rate is almost 70 percent lower than the national average (, and A 17 percent decrease in the use of sick leave over a four-year period for the non-exempt staff.

ABOUT THE AUTHOR Steven Cyboran is a vice president and consulting actuary in the Chicago office of Sibson Consulting. He leads Sibson’s Healthy Enterprise Initiative and has been actively involved in a variety of projects focusing on cultural transformation. He can be reached at 312.984.8558 or scyboran@sibson.com Copyright © 2011 by The Segal Group, Inc., the parent of The Segal Company. All rights reserved.

A Profile ~ Bill BAUN Manager, Employee Wellness programs, MD Anderson Cancer Center, Houston TX By Jane Sherwin

n 1976 Bill Baun was flat on his back, staring at a brick wall outside a hospital room. Six months later he was in a full body cast. A youth activities director at a church in Dallas, he had been rear-ended at an intersection. “Across the hall I could see a young man who had lost both legs in a motor cycle accident. I realized I was really lucky. I decided I would get up and walk again, and that I was going to help others not as lucky.”

Today Bill is Manager of Employee Wellness Programs at The University of Texas MD Anderson Cancer Center in Houston, where he has been since 1999. MD Anderson is an 18,000 employee hospital with the mission “to eliminate cancer in Texas, the nation, and the world,” as its website tells us. “We’re a cancer center,” said Bill, “and the high stress of cancer is part of our business—our clinicians must deal with this stress every day. At the same time, we’re a hospital, so we’re a wellness culture by nature.”

A Wellness Culture within Each Department Senior management, from Bill’s point of view, is fully committed to wellness and prevention. “Leadership gives people the opportunity to be well. Patients as well as employees benefit as they learn to be cancer survivors. We are all human—many employees face the challenge of weight loss, and obesity is a huge factor for some cancers. So when a staff member can put a hand on a patient’s shoulder and say ‘I’ve been there, too—I lost 40 pounds last year,’ it can make a difference.” “We work to set up a wellness culture within each department,” said Bill. “Departmental leadership accepts responsibility for their staff members’ wellness and we encourage the whole team to acquire the same knowledge, skills, and commitment. Everybody makes changes together.” The coaches work to get leadership support, and usually it’s a manager who requests help for a team. “But when a manager is not ready, the workforce team may invite us in and drive the program. “About three years ago we had a new coach who was a natural at small group work, and he set up a pilot intervention called ‘Simple Change.’ People had been calling him for individual coaching, and when he met with them, friends would want to join the coaching session. ‘Simple Change’ became a very successful small group change program where participants would get together and decide on their rules of engagement, meet weekly, and support each other in behavior change. We found that 80 percent of them were successful in what they chose to do, and 40 percent of the groups stayed together.”

Wellness is All About Relationships When Bill left his body cast behind in 1977, he decided to get a Master’s degree in exercise science—a brand new field at the time—from the University of North Texas in Denton. In 1981 he joined Tenneco, in Houston, Texas, which had set up one of the country’s first corporate fitness centers, free for every employee. “Tenneco was an oil conglomerate and oil was over $70 a barrel, so they decided to spend it on the health of their 101,000 employees worldwide. I started up 25 fitness and wellness programs around the world and managed the corporate headquarter center for 16 years—it was a blast, a lot of fun.” Under Bill’s direction, Tenneco was one of the first worksite programs to receive the C. Everett Koop Health Project Award.

“At Tenneco,” said Bill, “I learned how to work my way through the system and spot ways to build relationships—wellness is all about relationships, especially with leaders, and this is even more important in a big system.” Soon after he and a colleague had published the “Health Promotion Source Book for Small Businesses,” MD Anderson hired him as a ‘health and productivity consultant.’ “They had just started their wellness program for patients, and recognized the need to have healthy employees. Like most people they thought about wellness and prevention as programs and activities like classes and fitness centers.” But Bill believes that the heart of worksite wellness is not so much programs as changing the culture and getting and maintaining management support.

Wellness Works When it’s “In Your Face” Bill began at MD Anderson’s water coolers, putting up signs and quick tips about wellness, and quickly got at least 50 departments to be ‘water cooler program pilots.’ “It was just me for one or two years and I knew that wellness works when it’s in your face,” he said. “If it’s not in your face, it tends to get forgotten. It’s about perseverance and habits.” Today Anderson’s wellness coaches have a slogan: “We make house calls,” and they are all called ‘Coach.’ “In a hierarchical place like this, Manager Bill would be threatening. People see me and they say, ‘You’re the coach, aren’t you?’ Coach Bill has an easy and unthreatening ring to it, better than ‘personal trainer’ or ‘counselor.’ If you reach Bill’s voice mail you’ll hear, “Hi, this is Bill, your wellness coach.” His email signature ends, “Be well.” The MD Anderson wellness model relies on its internal staff to teach, facilitate support groups, and coach. Along with his four fellow coaches, Bill stays intimately involved with worksite wellness for MD Anderson employees. Their only outside vendors are MediFit Corporate Services, who run their fitness center; Weight Watchers; and several local massage therapists. Recently they’ve been focused on changing the work environment. When the vending machine contractor refused to switch to healthier choices, they found a new vendor willing to make those changes. Unhealthy foods in vending machines are now priced higher.

Lactation Rooms and Stress-buster Stations When a high-stressed physician in the palliative care unit said, “If we just had an elliptical machine I could use for five minutes that would break my stress level,” Bill arranged for an elliptical to be nearby. The hospital now has stress buster stations – an elliptical, a band chair for strength training, and a PreCor stretch trainer to increase flexibility and promote relaxation, which, Bill said, “takes up a small space and costs only $600.” Almost seventy percent of Anderson’s employees are female and at least 60 percent are in their childbearing years. Bill had learned at Tenneco the importance of lactation rooms and they now have 10 of these serving between 225 – 275 mothers each week. “They get companionship, they share their stories, and they feel better—so they get back to work faster, and their babies are healthier.”

Education and Social Networking Connections

“People can be at work up to 12 hours a day. They spend so much time here that their networking with each other is very important. Learning to be well and realizing that we don’t do this alone is what worksite wellness is all about – it’s the social networking connections at work that can make a difference in getting and staying well.” When he’s not coaching Anderson employees, said Bill, “I have to practice what I preach. I enjoy what I do at work so it’s hard to stop. I’m an avid walker and in-line skater. I do some weights but I like to be outside, chopping down trees, gardening. My daily stress relievers are meditation and taking time for myself. Move as much as you can and get outside after work. You can’t stop being active just because you get older.” He’s devoted to health at home and at work. “It becomes a passion, and my reward is doing well.”

In addition to department-specific programs, Anderson’s coaches offer hospital-wide courses. Several of the new courses for 2011 will include familiar topics like meditation and calming the mind, along with Attitude, the Difference Maker; Put the Brakes on Stress!; and Tickling the Funny Bone. When asked about social media and wellness, Bill said, “It’s a great way for people to engage each other, but not everybody is computer literate or has time to be on a computer, or a cell phone. In some cases you can be fired if you’re caught surfing on a computer at work. On line programming does not work for everyone. Wellness portals and websites have a role in wellness, but they have yet to replace the value of face-to-face coaching, counseling or bonding in a support group.

ABOUT THE AUTHOR Jane Sherwin is the owner of WordDrive Communications and a professional writer specializing in marketing materials for the healthcare industry. She works with healthcare clients to transform ideas and rough drafts into powerful communication tools, from newsletters and website copy to annual reports and sales proposals. WordDrive clients range from hospitals and home health agencies to health care consultants and associations. She may be reached at Jane@ WordDriveCommunications.com or 617.489.1834. WordDrive is a business built on more than thirty years of experience in copywriting and healthcare, including twelve with Blue Cross Blue Shield of Massachusetts, a leading national provider of managed health care coverage. To learn more, visit the website: www.WordDriveCommunications.com, where you can sign up for the monthly e-newsletter.

Utilizing Single Specialty Medical Centers By Alejandro Badia

uch debate is currently focused on healthcare reform, with emphasis on controlling costs, increasing access, while maintaining quality. While a daunting challenge, it is clear that the basic premises currently recommended to achieve this are fundamentally flawed. A very different approach may be necessary. The following points run contrary to current goals yet seem to work on a small scale. Why not expand this to a national, or even global, level?

Utilizing Subspecialty Colleagues is Beneficial in More Ways than One For starters, the recent focus on increasing primary care medicine may actually be more costly. While a necessary part of our medical infrastructure, the primary medical specialties need to work more closely with their subspecialized colleagues. This will paradoxically decrease health care costs in the long run. The exponential explosion of medical knowledge has clearly made it impossible for a physician to have even a cursory knowledge of all specialties, let alone subspecialties. The result is that a general physician will often miss the diagnosis, and currently more relevant, will expend much greater resources in order to arrive at the diagnosis; let alone formulate the appropriate treatment plan. For example: It is not uncommon that a patient presents to me, a hand specialist, with wrist pain. While my experience and clinical acumen will often lead me to the diagnosis immediately by just listening to the patient’s complaints, the patient who comes from a primary doctor may come see me with an MRI already performed, a battery of blood tests, and perhaps even a course of physical therapy already in progress. The problem is that this patient may simply be suffering from DeQuervain’s tendonitis, a very common condition responding to a single corticosteroid injection in 80% of cases as per the scientific literature. I am so confident about the result that these patients are typically not even given a follow-up appointment. Hence, the difference is clear: the subspecialist makes the diagnosis much faster, with superior resolution of the clinical problem and at much less cost, utilizing less testing and imaging studies. The issue is that this same scenario applies in nearly all fields of medicine. Even in other orthopedic areas, I as a hand surgeon would be completely out of my league if evaluating a patient presenting with something as common as intractable low back pain. This diagnosis alone occurs in 65 million Americans and costs our society more than 100 billion a year! If I feel ill prepared to manage this problem as an orthopedist, how can a general internist or perhaps even a chiropractor be sufficiently qualified to ensure that they are not missing spinal stenosis, a midline herniated disc, or perhaps a spinal cord tumor? It is clear that each diagnosis, whether glaucoma, lymphoma or renal hypertension, should be managed by the appropriate specialist; from the outset and till symptom resolution/management.

Controlling Costs A further problem is the intrusion of non-trained, essentially laypersons, into the fabric of American medicine. This means that non-medical personnel are frequently interfering with care, or serving as “costcontrollers” when they are really superfluous. Do physicians really need a pencil-pusher “authorizing” care when their staff calls the insurance carrier to essentially ask permission to perform a procedure or order a test? This layer of bureaucracy is redundant and not costeffective. It slows the process and adds cost to the system. Are MDs not the best barometer of whether a test is needed? Are physicians not subjected to the most arduous training and education of most any profession while, in most cases, maintaining a certain ethical standard dictated by a professional oath of conduct and enforced by medical societies? The amount of money, and time, saved by avoiding this validation step would greatly offset the occasional physician that over-utilizes, or even unscrupulous provider. A major cost issue remains the overly prominent central role that the hospital systems continue to assume. This is very likely due to the powerful hospital lobby and

is something that needs to be gradually scaled down. The answer is not only to move feasible services into the outpatient care realm, but also to make them increasingly specialized. A major hospital system in Miami area has long recognized this fact and astutely formed a large network of efficient and accessible outpatient urgent care and diagnostic centers. Ophthalmology and endoscopy centers long ago have realized this gain, and furthermore, free market forces have actually driven down costs in many scenarios. Multi-disciplinary teams can most effectively, and prudently, address clinical problems. KNG Health Consulting found in a seven year study that moving a variety of surgical procedures into ambulatory surgical centers (ASCs) away from hospital centers, greatly decreased the cost of treatment. Despite concerns to the contrary, there was no overutilization, or even greater self-referral of patients, even when physician-owned. Over-burdensome government regulations, such as Stark I and II laws have unfortunately inhibited this growth not allowing potential cost savings to be realized. Further expansion of government bureaucratic control would be even more detrimental.

do not resolve the problem within several days. That specialist would then determine if further testing is truly necessary, such as an MRI to look for a disc herniation or other problems. He may be referred to a chiropractor for manipulation, a physiatrist or perhaps a physical therapist if appropriate. If surgical microdiscectomy is indicated, that too can be done in the same facility. All this would likely be done within several visits, if the patient is not discharged earlier, and the multitude of patients with similar conditions would sharpen each practitionerâ&#x20AC;&#x2122;s clinical skills. All one has to do is ask a patient who has been seen in this type of facility what their opinion is. Patient satisfaction tends to be high. This approach can be used for many different areas of medicine. We have seen the advent of orthopedic urgent care centers around the country in select markets. We have recently seen OrthoNOW open in the Doral area, blazing the trail for this concept in South Florida. We simply need to expand on what we already know.

Alternative Ideas The current hypothesis suggests that specialized centers contain not only ASCs, but also all the necessary diagnostic, consultation, and rehabilitative services under one roof in order to promote efficiency, while delivering the most optimal care possible. Clinical studies can also be performed optimally in this environment, where large cohorts of patients with similar diagnoses can be studied, and patient outcomes can be over more successful, as well as cost efficient. Patients would have the opportunity to select these centers of their own accord, and be treated if appropriate, or referred by a system of less specialized physicians, or even clinical nurse practitioners, who could best determine what venue the patient should pursue. This â&#x20AC;&#x153;one stop shoppingâ&#x20AC;? concept represents a common sense approach to health care. Referring to our previous example, a middle aged laborer complaining of low back pain would be seen, perhaps even without an appointment, in an orthopedic urgent care center. An orthopedic physician assistant, or preferably, a family practice physician with training in musculoskeletal medicine would do a cursory physical exam, order appropriate tests such as an X-ray, and have the spinal orthopedic surgeon see the patient in follow-up if initial analgesics, NSAIDs and bed rest

ABOUT THE AUTHOR Alejandro Badia, MD, FACS is a hand and upper extremity surgeon, and chief of hand surgery at Baptist Hospital in Miami. In 2008, he completed the Badia Hand to Shoulder Center and the Surgery Center at Doral. More recently, Dr. Badia inaugurated OrthoNOW, the first immediate orthopedic care center in south Florida. He can be reached via www.drbadia.com

Expatriate Health Insurance: How to Apply Moratorium or Medical Questionnaire By Olivier Le Faouder

What is a Moratorium Underwriting?

his is a common form of underwriting used by private international health insurance companies. It covers each individual, family, small group under a policy excluding any medical conditions that have been treated with advice, treatment or medication in the five years preceding the date of the insurance. The moratorium is defined as a qualifying period of 24 months for treatment costs attributable to an existing medical condition and its consequences. After a continuous insurance period of 24 months, private health insurance companies will reimburse the eligible expenses incurred for existing medical conditions if the insured person did not

suffer any symptoms and did not require treatment, and did not receive or require any medication during this 24-month period of moratorium. If the insured submits a request for reimbursement for care, it will be reviewed by the insurance company. The insurance company will consider whether or not the patient had a medical history and whether the symptoms are before the date of the subscription. The subscription for an insured is easy with the moratorium. It may even make the purchase online as travel insurance without formalities. This process still requires a special attention. Private insurance companies take advantage of the moratorium to avoid paying claims and bear the burden of proof to

the insured. The insured must justify in many cases with medical evidence that he did not have a medical history. The date of subscription is also often a source of conflict. In addition to having no medical history; determining a disease that happens unannounced is very complicated. The insured must be proving his good faith. It may be also difficult for individuals to initiate an action in a court against a company with a head office in countries where consumer’s rights do not exist. Our advice in this case is to provide with its application medical records with a complete check up. Legal line will be defined.

What is a medical questionnaire underwriting? You must complete a medical questionnaire with your private medical application. Your good faith is important. You can enter inside the expatriate health plan without exclusion if you have a good health or with partial, total exclusion or with loading premium. If they would like pre- existing medical conditions to be included, this will apply above all to the questions concerning the present state of health, past or present illnesses, disorders and symptoms, as well as treatment. This process of accession is longer and more complicated and requires medical records. Each insurance company appreciates its risk. It depends on the ratio of premium

/claims by country and area of cover. You must also negotiate with companies on exclusions and the appreciation of risks and provide some concrete medical evidence. Protection for the consumer is more important if you apply with a medical questionnaire.

The Conclusion There are two different ways of thinking in international health; the moratorium used by English brokers and medical questionnaires used by European brokers. We find that companies are moving more and more towards medical questionnaires and the cancellation of pre-existing & chronic conditions. I think the moratorium is the root of many conflicts if it is not properly explained to the insured. It is very important in this case to give good advice and not to just sell without professionalism.

ABOUT THE AUTHOR Olivier Le Faouder, managing director AOC Insurance Broker – Paris – Casablanca Bangkok – Shanghai (French European broker member Orias) – Expatriates Health insurance comparator & Travel insurance online. Oliver LE FAOUDER previously worked as an executive in the French tax administration and for 15 as financial expert consulting services to companies with a multi-disciplinary back ground.

Healthcare and the Impact on the Federal Budget By Melvin J. Howard

here appears to be at least as many permutations and combinations available for presenting the US Federal Budget and Government Spending data as there are years that it would take you to count to $2 Trillion dollars, which is about 60,000. Note that in the US the number One Trillion is One Million times by One Million, or 10 to the power of 12. For the mathematically inclined, the correct mathematical definition of One Trillion is One Million to the power of 3, and the correct mathematical definition of One Billion is One Million to the power of 2. But in America numbers work differently, so it came to be that One Billion got redefined as One Million to the power of 1.5, and One Trillion is redefined as One Million to the power of 2. The effect and advantage of being the Imperial Super Power is that everybody else in the world now had to adopt this number conversion.

Rome is Burning The U.S. Federal Budget has been in the news a lot lately both Republicans and Democrats both showcasing their version of the numbers. How you present the Federal Budget depends entirely on the bias you start with and the point you are trying to make. Therefore I decided to admit the bias up-front and then you can better decide what to do with the data. My bias in looking at U.S. federal spending was the thought that maybe we might be on fire just like the Roman Empire was over 1,000 +-years ago. To be sure, the Roman Empire had many similarities with the modern U.S. Empire - both being Empires built on a combination of clever legal systems, hard-work, confidence, much brutality in military conquest and extensive use of slave labor, coupled with a system of desirable, tempting, and free entertainment to warm the masses to the Empire (think Roman Idol), as well as erratic spouts of helpful assistance to the poor. Certainly also, a widespread Roman currency and trade system, and an extensive taxation and government spending program were just as critical to the success of the Roman Empire, as they are now in today's American Society.

The comparisons of Budgets started with finding a Roman budget at a time around when their leaders stopped being elected and instead were "appointed" and when ancestral lines of Emperors became very popular. So I started with the early Empire days of the 1st - 2nd Centuries AD. The approach I have taken is based on historical data from those days, to calculating the Roman budget in this period. The total Roman budget was about $1 billion sesterces, a common Roman currency that started in the BC years as about 1/4 of the Moneta denarius. These are estimates for the Roman budget in 150 AD broken down into the following expenditure categories. Roman Empire Budget Distribution Source of Roman Data Expense Item Percent Outgo:

• Military 70% • Civil Service - Judiciary, Police, Government Departments 10%

• Social Spending 5% • Economic Infrastructure 5% • Other - Mostly Foreign Affairs 10% Now compared to U.S. Actual Government Spending in earlier years subtracting both Social Security and Medicare, which have been fully self-funded by separate taxes (the FICA taxes) since the early 1980s. Then you subtract interest on public debt for comparison purposes since the Roman Empire did not have a consistent, well-developed system of Sovereign debt issuance like America does today. Some other adjustments to be made to U.S. Spending were to include Veterans Benefits, Military Retiree benefits and Military Assistance to the Provinces (Countries) of Judaea and Egypt (Israel and Egypt) with Military Spending. The inclusion of benefits to ex-military employees is consistent with the way the Roman data was derived, and the inclusion of military aid to Israel and Egypt was done because these were the two most expensive outer-Provinces to maintain under both Regimes. The following distribution of expenses on a comparable basis can be derived from the full current Budget of the U.S. Government. 33

We are focusing on the demands on the Budget coming from the aging of the population and society's increasing medical expenses. America’s Budget Distribution Expense Item Percent Outgo breaks down to something like this:

• Military 40% • Civil Service Admin, Justice, Treasury, Fed Civil • • •

Retirees 10% Social Spending - Medicaid, Food, TANF, Unemployment, Housing, SI 30% Physical and Economic Infrastructure 10% Other - Education/Training, Research, Foreign Affairs 10%

Clearly the data indicates that social spending in the Roman Empire was generally at a very low level. However social spending tended to happen erratically in much larger amounts, depending on the Emperor of the day, and the need to win over public opinion. What is clear from looking at the two budgets is that the current U.S. budget has more regular proportions of social spending, especially in comparison to military spending. However, it should be noted that the U.S. budget looked much more Romanesque in earlier decades of the last century, notably during the 40s for WW2 and during the 50s in gearing up for the Cold War, where military expenditures were close to, and sometimes even exceeded, the Roman proportion. The move from a Romanesque budget of the 1950s to current U.S. spending distribution has a lot to do with increased healthcare expenditures such as Medicaid, and the introduction of things like the Earned Income Tax Credit, and changes to Unemployment, Housing and Food Assistance Programs. Note that most of these social spending items included in the 30% fall under the grouping of "Means Tested Entitlements" which means that they make up the social safety net for people whose income and assets fall below a certain threshold. The other primary social spending benefits or social safety net items are Social Security and Medicare, which apply to Retired and Disabled Persons and are not means tested. As noted earlier these benefits have been self-funded through separate employer and employee contributions (known as the "FICA taxes") for the past two decades and half. In general, rising medical costs affect both Medicare and the means

tested healthcare entitlements such as Medicaid. In fact, one of the Historical Data Tables in the Budget shows total government spending on all health programs to have increased from about 2% of the Budget in 1962 to just over 10% by 1980, to almost 25% or one quarter of the Budget by the year 2001.

The USS Ark of Healthcare Reform As anyone with a health insurance policy will tell you, healthcare costs under private sector coverage continues to rise. Overall, an increasing amount of America's total Gross Domestic Product (GDP - a measure of the total economy) is spent on healthcare. To keep score of the size of an economy and the size of national income people often talk about GDP. This measure of national income is also equivalent to Annual Consumption Expenditure plus Government Spending plus Investment - which are the only three places your money can go. That is, any income you get either goes to taxes, you spend it or you invest it. U.S. GDP is about $14.6 Trillion US dollars. Consumption Expenditure makes a Trillion dollars a year. Today healthcare expenditure makes up about 16.5% of U.S. GDP. About 30% of this is picked up in Government Spending; the rest is in private spending. At the current rate of growth, healthcare costs are predicted to nearly double to $4.5 trillion in the year 2019. At that point, those costs will account for 19.3 percent-almost a fifth-of our GDP. America spends more on healthcare as a percent of its GDP than any other developed nation, but has less public coverage for this cost and a large uninsured population. So, the high spending on healthcare in the U.S. must be explained by something other than a general concern that everyone has adequate care. To a very large extent the high level of American healthcare spending is a result of America becoming victim of its own technological success, its sedentary lifestyle and a culture obsessed with longevity, overcoming natural cycles and the desire to "stay young". The latter appears to be common to inhabitants of Great Empires of the past. This cultural obsession, fed by medical technologies far superior to those of any other country, may suck up so much of the US economy that it won’t be able to sustain its global super power status. Indeed it is perhaps the very fear of this that is really driving the attempt to reform and redefine Healthcare, Social Security, Medicare and Medicaid.

Now moving on to some of these other expense items, it should be noted that "Other Spending" includes Foreign Affairs expenditure other than the expenses of maintaining the outer provinces of Israel and Egypt, which are included in the Military item. Under both Empires so-called "foreign aid" is or was an important part of keeping peace with peripheral provinces or countries. Unlike Rome, the U.S. also successfully uses loans through various multi-lateral institutions such as the IMF, World Bank and Inter-American Development Bank to maintain optimal relations with peripheral sovereigns. This use of loans gets to one of the fundamental differences between Rome and America - the role and leverage of the financial system. The U.S. success is largely due to the success and complete faith in its monetary system. In contrast, the Roman Empire's monetary system was almost entirely metal based and while there was easy access to credit for the ruling classes this was not true for other classes. There appears to be much debate among historians about what stopped the Roman Empire from having an industrial revolution. But whatever one's opinion, surely a pre-requisite is a highly leveraged, monetary system with sophisticated, widespread access to credit. But Rome never got to such sophistication with its financial system. This provides us with another reason why its success was always more driven by military conquest than anything else. In contrast, for the modern American super power, financial influence is on a par with military

power, and both feed off each other. The financial success of the American Empire has also made its tax collection process far more efficient than any previous Empire before. In Roman time the tax collector had to go door to door to collect heavy coins, cattle, feed etc. But still just like then the biggest problem being with collecting from the rich. Remember the biblical character of Noah and the Ark warned of an impending storm like no other storm in history. Well our storm has arrived in the form of healthcare spending. And if we don’t take swift action the USS Ark of Healthcare Reform will close its doors and sail off leaving the bulk of its people medically stranded and unprotected. And just like Noah’s Ark the USS Ark of Healthcare Reform will not have any place to dock instead it will continually drift in a sea of red ink! This week one year ago, President Obama signed the historic Patient Protection and Affordable Care Act. Now maybe the USS Ark of Healthcare Reform can see port and start docking preparations.

ABOUT THE AUTHOR Melvin J. Howard is Principal of the Howard Group a family office that specialize in Foundations, Trusts, Limited Partnerships, Private Equity, Capital Markets, and Health Care Trade Issues. We are registered federal lobbyist that pursues economic and international public policy initiatives on behalf of U.S. companies with interests’ abroad more specifically international global health and trade issues. thehowardgroup@ilike2invest.com

The International Traveler and Blood Transfusions By Katherine L. Harmon

Blood Donors

aintaining a safe blood supply is a critical component for public health, especially in developing countries. Multiple studies have shown that purely voluntary donations are the safest way to maintain a blood supply free from transmissible diseases such as HIV and hepatitis. When compensated donations are allowed, either through monetary measures or through other recruitment means by promise of rewards or even from families wishing to donate, reports of disease

rate among nationsâ&#x20AC;&#x2122; blood supplies rise tremendously. Thus, efforts to recruit voluntary donors who give routinely have attempted to seek new motivational efforts. This is important for the international traveler because safe blood supply outside of an industrialized western nation may be difficult to be assured of in a time of need and with motor vehicle accidents being the leading cause of trauma and injury in the traveler, the need for blood during a vacation or ex-patriation may actually be significant. Recently, creative recruitment efforts have been initiated in Africa and other areas of the world to address this dire need for safe blood.

Through social media and networking sites, community centers, and peer pressure, youths are encouraged to become donors at an early age and return regularly. This serves multiple purposes: it involves youths in an endeavor that fosters a feeling of community, helping them become invested through enhancing their sense of belonging and purpose. Regular donations also encourage a healthier lifestyle, as each donor is counseled extensively on what is expected of them in terms of safe sex practices, abstinence from illicit drugs, reasonable alcohol and tobacco use (preferably none), and general health. Developing a corps of young, healthy blood donors is a win-win for developing countries: not only does it help to fill a critical need for life- saving blood products, it also promotes a healthier citizenry and a sense of connection within a community. Nor does such a corps need to be necessarily large. Estimates suggest that for most countries, blood supply needs could be met if 1-3 percent of the population donates blood.

Infections in Donated Blood In several nations across Europe and Asia, several methods have been employed post collection, to make the blood supply safe from infections that are not routinely tested for. Concerned with the possibility of transmitting some disease like dengue or chikunguya, these countries are employing methods like UV light sterilization as well as adding certain chemicals to collected blood to boost their safety. However, some recipients have had side effects from these “safety” procedures and therefore these methods are not universally employed. Other nations with advanced laboratories who can test for more diseases, like the U.S. are testing for additional diseases besides the standard HIV, Hepatitis B and C and Syphillis. Calls for looking for Chagas disease, dengue and other blood-borne pathogens that could be common to the population are also screened for. One of the most common transfusion transmissible diseases in the world is malaria. Malaria presents a unique challenge to developing a safe blood supply. Donors may have such low levels of parasitemia that they escape antibody detection, the method of choice for identifying infected donors. Also, while malaria antibody testing is 95 percent sensitive and 99 percent specific, applying it in places where malaria is endemic is entirely impractical. To cover all species of Plasmodium that affect humans on a large scale would be costly and inefficient. Malaria antibody testing is similarly unrealistic for traveler screening in

non-endemic areas. Careful questioning and ensuring that potential donors from endemic areas (or passing through such areas) are cleared is far more efficient. The American Association of Blood Banks (AABB) recommends deferring donation for one year following travel to an area endemic to malaria; for immigrants or residents of malaria-endemic areas, or former residents of endemic areas who now live in non-endemic regions and return to visit, the AABB recommends deferring donations for three years following the most recent visit. Additionally, persons diagnosed with malaria should wait three years after treatment before donating blood.

Screening Blood before Transfusion According to the US Centers for Disease Control and Prevention (CDC), many countries simply do not have procedures to screen for infectious diseases, and 39 countries report that they release blood for clinical use without testing for transfusion transmissible infections. At least 40 countries have reported no testing for HIV, hepatitis B or C, and syphilis in blood donations. Travelers should therefore receive blood transfusions only in life-or-death circumstances when overseas. The CDC recommends that if a transfusion is absolutely necessary, every effort be made to ensure that basic screening occurs. When sixty-five percent of the world’s blood supply is provided by industrialized nations, home to only one-quarter of the world’s population, according to the World Health Organization (WHO), it is possible to see where there could be a potential blood crisis. In 2007, 25% of responding countries to a poll regarding their blood supply issues, said that their blood came from voluntary or unpaid donors, the safest form available according to the WHO Blood Safety Survey Report. In addition to assistance in how to recruit voluntary donors, many countries are being given assistance in how to administer transfusions effectively. In numerous instances, nations are giving transfusions when they are unnecessary and other means of life-saving care could be rendered instead. Blood is a resource for these countries that cannot afford to be wasted and minor education can go a long way towards rectifying many of the complex issues present. As new and more effective testing methods come to market, with increased speed and efficacy, reducing cost and enhancing sensitivity, developing nations can increase the safety of their blood supply along with their with the novel methods they have employed.

As the vast majority of blood needs for travelers and ex-patriates are from trauma arising from motor vehicle accidents, concern over the safety of the blood or blood products is a valid one. Advance understanding of how the nation screens for this prior to travel are certainly advisable and can influence purchasing of evacuation insurance and orders. What can be done? Ensure that your hepatitis B immunizations are up to date and that you have received the entire series prior to travel, especially if you travel to developing countries or are at high risk for serious injury. Pregnant travelers should especially consider and investigate the safety of the blood supply of their destination country, as they are more likely to need an emergency transfusion. If you are traveling to malaria endemic nations, be aware of this. If you are not on chemoprophylaxis because you are not in a particular area known for malaria yet receive a transfusion, you may still receive blood from someone with parasitemia in their bloodstream. Should you develop symptoms such as fever, post transfusion, let your healthcare provider know immediately that malaria might be in the differential diagnosis so that medication could be started right away. Donating your own blood for travel is impractical due to storage issues and traveling, however, adding to the blood bank is always appreciated and all types are needed. For more information on donation, please see: www.redcrossblood.org/donating-blood/ eligibility-requirements.

Resources • “Traveling While Pregnant,” US CDC, Travelers’ Health Yellow Book, 27 July 2009. http://wwwnc. cdc. • gov/travel/yellowbook/2010/chapter-8/travelingwhile-pregnant.aspx • “Going to Scale: The Power of Partnerships,” The US President’s Emergency Plan for AIDS Relief Botswana, 2006. www.cdc.gov/botusa/ docs/2006AnnualReport-FINAL-508.pdf • “Public Health Case Study 2: Malaria in Pennsylvania,” US CDC, 8 February 2010. www.cdc.gov/ malaria/references_resources/ interactive_training/ph-2/ • “Screening Donated Blood for TransfusionTransmissible Infections,” World Health Organization, 2010. • www.who.int/bloodsafety/ ScreeningDonatedBloodforTransfusion.pdf

ABOUT THE AUTHOR Katherine L. Harmon PA-C is the Director for Health Intelligence at iJET Intelligent Risk Systems in Annapolis, Maryland. She and her staff monitor for global outbreaks of infectious diseases as well as health issues and publish alerts for an array of clients to advise of potential problems and proposed solutions. They also publish a weekly newsletter on infectious disease news and topics of health security interest; The World Pandemic Monitor. Prior to joining iJET, Katherine enjoyed more than 15 years of clinical experience in Occupational and Internal Medicine as well as consulting on security related issues.

Tooth-Enomics Consequences of Bad Oral Hygiene

ental care can be expensive, but not taking care of your teeth is even more costly and can lead to more difficult and even more expensive health care issues over time. Avoiding good oral hygiene is like going to sleep with a full grin and waking up like Rip Van Winkle needing a full set of dentures twenty years later. And talk about halitosis! Can you imagine waking up after two decades and never brushed your teeth during that whole time? No wonder his neighbors ran away from him. No matter where you live, whether itâ&#x20AC;&#x2122;s in upstate New York, London, Mexico, Tokyo, or anywhere else, good oral health is essential to avoid problems with more severe medical issues. You need an affordable way to keep your smile and avoid problems later. Dentists and health officials have pointed out that not only does taking care of one's teeth mean better, stronger teeth, but it also is conducive to healthier habits and outcomes throughout the body, as reported by the Utah Valley Herald Extra. A number of studies in the last couple of decades have looked at the correlation between dental health and overall physical health and found some connections. One study found that women with periodontal disease were more likely to have low birth weight or premature babies than

By Mark Roberts women with healthy gums. Other studies have found a connection between periodontal disease and heart disease may be because the type of bacteria that grows in the mouth produces the same type of chemicals that cause inflammation in the cardiovascular system. Of course, that doesn't mean not being the most vigilant about brushing your teeth means you're going to have a heart attack, just that there likely is a connection between severe gum disease and cardiovascular problems. The bad dental health news is that, unlike a cold or an ache that will run its course, dental problems aren't self-correcting. A soft spot left on its own can become a cavity, and a cavity ignored can become an abscess. Sometimes people feel the effects of poor dental hygiene in other ways -- like making a less-thangood first impression at a job interview. People notice people's smile; that makes a big impression on people. You can't get rid of that factor either. Appearance in society is very important.

Stop Dental Problems Before they Start According to a report issued by Employee Benefit News, dental illness is the most common of all chronic health concerns and accounts for significant loss of workforce productivity and significant health care costs. Studies show workers who get their dental care completed

and maintain good oral health do far better on the job than those who do not. Oral health reduces the chance for emergency visits and the pain and discomfort that can harm a worker's focus and confidence. Workers, confident about their family's health, are more focused, productive and secure. Absenteeism for dentist visits, pain, discomfort and poor self-confidence harm production, employee confidence and quality of life across the corporate community. Reports over the last 10 years provide some detail regarding the impact of oral health on the workplace; and itâ&#x20AC;&#x2122;s getting worse as dental benefits are axed from employee benefit plans, and workers are forced to go without dental insurance or find other options to take care of dental expenses. In the US, workers experience 164 million hours of lost work time each year due to dental visits. The annual cost for general dental care is estimated at $60 billion dollars, which does not account for cranial facial care and care for oral problems, such as oral cancer or chronic pain syndromes. These medical costs are estimated to average $100,000 per individual for the lifetime care required to address these oral illnesses and developmental problems over time. Overseas, where dental care is less important in many cultures and in many parts of the world with very poor access to health care, the statistics are even more staggering. Preventive dental care could significantly reduce loss of productivity and catch problems before they become chronic or severe, according to AllBusiness.com. Regular dental evaluations may also reveal surprising information about seemingly unrelated health issues. Medical professionals have identified at least 120 medical symptoms that can be detected in the mouth during routine dental checkups, including skin diseases, mental illness, diabetes, thyroid problems, leukemia, cancer or hardening of the arteries. In fact, bleeding gums, etched enamel and other tissue changes in the mouth are often the first clues to serious health problems. Medical studies have also revealed that pregnant women with gum disease are seven times more likely to have babies that are born too early and too small. According to Colgate.com, maintaining good oral hygiene is one of the most important things you can do for your teeth and gums. Healthy teeth not only enable you to look and feel good, they make it possible to eat and speak properly. Good oral health is important to your overall well-being. Daily preventive care, including proper brushing and flossing, will help stop problems

before they develop and are much less painful, expensive, and worrisome than treating conditions that have been allowed to progress. In between regular visits to the dentist, there are simple steps that each of us can take to greatly decrease the risk of developing tooth decay, gum disease, and other dental problems, which include brushing and flossing between meals and avoiding sugary treats.

Dental Insurance is Essential No Matter what Country youâ&#x20AC;&#x2122;re in The economic recession has served as a wakeup call for people to protect themselves, their loved ones and their assets and has made the importance of strong benefits more clear than ever before. So, what are your options if you live in the US and are traveling or living overseas and you need dental work done when you are there? What about foreign nationals that are visiting or living in the US, what do they do? According to McKinley International Risk Management Group, international benefit managers don't pay much attention to expatriate group dental insurance, but they should. U.S. citizens working overseas for an employer expect expatriate dental insurance plans and all the major carriers will offer it in conjunction with an international group medical insurance program. Unless you have a very large group, expatriate medical insurance carriers will not offer expatriate dental on a stand-alone basis. Unfortunately, most U.S. expatriates will not go to a dentist in their host country for several years until they feel comfortable there, and in some countries they will never go to the dentist for good cause. Expatriate group dental insurance always needs to allow dental care back in the home country and the expatriate may have family back in the home country or a child studying in another country, so expatriate group dental insurance must be global in scope. Insufficient dental coverage can prove to be very expensive as the cost of dental treatment in most countries is very high, according to Pacific Prime. Insurance companies normally have a waiting period, often up to a year, before they will accept any claims for treatments. This period can vary between individual insurance companies and it is important to check the specific conditions when considering dental coverage. Almost all insurance companies accept pre-existing dental problems. Most individuals who have had been to a dentists are likely to have undergone treatments such as simple fillings, tooth cleaning and root treatment. It is therefore extremely rare for the individual not to have

any pre-existing conditions. This is why the insurance company will cover the pre-existing conditions after a period of time. Insurance companies normally offer two levels of dental coverage to enable the client to select the most suitable planâ&#x20AC;&#x201D;routine treatment including preventive and restorative dental procedures, and major treatment such as crowns, periodontal root scaling, and orthodontia. International dental plans are meant to cover any dental work or dental repair you need while you're on vacation or traveling abroad for any reason. While these plans can be pricey, they can be worth everything you paid if you end up having tooth trouble in Manila, thousands of miles away from your regular dentist. If you travel frequently, this is something that you will want to research; but the costs at first glance can be quite prohibitive, according to the Insurance Salesman online. One way to keep your international dental insurance premiums low is to make sure that

you are a good candidate for their coverage. Keep in mind that insurance companies are specifically forprofit. If you can show them that you are a low risk investment, than you will be much better off. Also, as you're researching rates, consider the overall time that will be required to go through a claim made regarding a foreign country. If the country is non-English speaking, you will need to translate the paperwork into English before your insurance agency will be able to process itâ&#x20AC;&#x201D;certainly a concern to bring up with your insurer. Who will be responsible for the translation? Will you be able to get affordable dental insurance at all? Will they accept a translation that you do, assuming you are a native or fluent speaker of the language? To keep your international dental insurance affordable, you may need to shop around a little. While you can get advice online, you should also consult with people who are familiar with world travel. In terms of convenience, you may wish to speak with your present insurers and see if they can add something to your present policy. It

provider to receive most dental services at discounted fees. When you take a closer look and compare cost, access, waiting periods and benefits, it is clear Discount Dental Plans are an immediate value.

will be in your best interest if you can find a company with underwriters who are familiar with international insurance issues.

Discount Dental Plans If you are on a very tight budget as an individual, or your company has limited funds for an employee dental plan, you may wish to consider a discount dental plan. Whether you are a citizen or not, you can find excellent savings for extremely affordable rates—often at 10% of what dental insurance costs. There are no residency requirements, and usually no minimum participation for groups is required. Members of discount plans receive immediate savings through a network of participating dental providers. The only downside is that not all dentists participate in discount plans. However, reputable companies like Careington International or Aetna provide substantial nationwide networks, and the savings on some procedures can be as much as 60%. Membership in discount plans often includes the entire household at no extra cost, and you can use them as often as you need with no penalties or utilization issues from overuse. Discount dental plans are designed for individuals, families and groups looking to save money on their dental care needs. Participating dental care providers have agreed to accept a discounted fee from plan members as payment-in-full for services performed. As a plan member, you simply show your membership card when visiting any participating plan

Some dental insurance plans don't make payments to the dentists as fast as the dentists would like. Dealing with insurance claims can be a real hassle for a dentist office. Dental discount plans are easy to administer. However, using a discount plan overseas can be difficult, typically because dentists do not participate in networks and the business model does not translate well in other countries. You may or may not be able to personally negotiate a discount. That depends on whether the dentist is willing to make a deal with you, and if you pay in cash. Often, payment by credit card reduces your savings as the provider must pay a fee to the card company to accept payment. Discounts may only be 5%-10% in most cases. The discount dental plan concept is common in the US and has been around for decades. However, outside of the US it is an unknown and little used. One exception is a scheme called Healthy Discounts in the UK offered through Munroe Sutton. It works the same way and provides good savings with a network of dental practitioners for a low monthly fee. An optical discount network is even part of the program at no extra cost. Passing on a dental plan is not the best use of your money, and it sure doesn’t help your personal prospects financially, physically, or socially when you ignore dental care. The economics of keeping your gums and teeth healthy—Tooth-enomics—is worth strong consideration when you determine what dental plan works best for you.

ABOUT THE AUTHOR Mark Roberts’ professional sales background includes almost 30 years of sales and marketing in the tax, insurance, and investment markets. Currently his key focus is developing relationships with large national client groups. Additionally, he assists individual retail consumers and health & life agents interested in health savings and services. Mark also is a licensed life, health and accident insurance agent.

Chicago, Illinois, USA.

October 25th-28th, 2011

Marriott Renaissance Schaumburg Convention Center Hotel